Migraine is a common neurological disorder that remains under-recognized, under-diagnosed and under-treated. The disorder imposes a large burden on individuals and the wider community in terms of migraine-related disability and high healthcare and societal costs. Moreover, there is a discrepancy between the availability of effective pharmacologic intervention and the level of treatment that patients with migraine actually receive. A disease management program can benefit individuals with migraine and society in general, by delivering improved care within a cost-effective framework.

Disease management programs aim to reduce the burden of illness by identifying key factors that influence disease outcome. Herein, we consider a clinic-based migraine disease management program. Currently, step care remains the most common approach to migraine management. However, this approach frequently delays effective therapy and leads to patient dissatisfaction and lapse from medical care. Stratified care is an alternative approach to migraine management and tailors the choice of therapy to the individual treatment needs of patients.

The Migraine Disability Assessment (MIDAS) Questionnaire offers a simple and reliable measure of migraine—related disability. It assesses the overall impact of disease and reflects illness severity and thereby helps guide the physician to the appropriate treatment.

Implementation of stratified care, based on illness severity assessed by a disability measure, increases the likelihood that patients with migraine will receive the appropriate treatment plan from the initial consultation. In a randomized trial, step-care and stratified-care approaches were compared using aspirin (acetylsalicylic acid) plus metoclopramide or zolmitriptan 2.5mg oral tablet for the treatment of migraine attacks. The study demonstrated that stratified care produced significantly better clinical outcomes and improved the cost effectiveness of healthcare delivery for migraine compared with step care strategies.

The 5-HT1b/1d receptor agonists (the ‘triptans’) are migraine-specific agents that have revolutionised the treatment of migraine. They are usually the drugs of choice to treat a migraine attack in progress. Different triptans are available in various strengths and formulations, including oral tablets, orally disintegrating tablets, nasal sprays and subcutaneous injections. In Europe, sumatriptan is also available as a suppository.

Specific differences among the triptans exist, as evidenced by different pharmacological profiles including half-life, time to peak plasma concentrations, peak plasma concentrations, area under the concentration-time curve, metabolism and drug-drug interaction profiles. How or whether these differences translate to clinical efficacy and tolerability advantages for one agent over another is not well differentiated. However, delivery systems may play an important role in onset of action.

Given that the clinical distinctions among these agents are subtle, identification of the most appropriate triptan for an individual patient requires consideration of the specific characteristics of the patient and knowledge of patient preference, an accurate history of the efficacy of previous acute-care medications and individual features of the drug being considered. The selection of an acute antimigraine drug also depends upon the stratification of the patient’s migraine attack by peak intensity, time to peak intensity, level of associated symptoms such as nausea and vomiting, time to associated symptoms, comorbid diseases and concomitant treatments that might cause drug-drug interactions.

Individual patient response to the triptans seems to be idiosyncratic and possibly genetically determined. Therefore, a set of specific questions can be used to determine whether a currently used triptan is optimally effective, whether the dose needs to be increased or whether another triptan should be tried.

The clinician has in his/her armamentarium an ever-expanding variety of triptans, available in multiple formulations and dosages, which have good safety and tolerability profiles. Continued clinical use will yield familiarity with the various triptans, and it should become possible for the interested physician to match individual patient needs with the specific characteristics of a triptan to optimise therapeutic benefit. Use of the methods outlined in this review in choosing a triptan for an individual patient is probably more likely to lead to migraine relief than making an educated guess as to which triptan is most appropriate.

The wide clinical spectrum of migraine frequently challenges the physician's diagnostic acumen. A structured approach to the patient and a better comprehension of this variability of presentation, should translate into better quality of care for migraineurs.

Opinion statement

Migraine is a common, chronic neurologic disorder that affects approximately 12% of the adult population in Western countries. Once migraine is diagnosed, illness severity must be assessed. Clinicians and patients should then work together to develop a treatment plan based on patient needs and preferences. The goals of treatment usually include reducing the intensity and duration of acute attacks, minimizing the frequency of attacks, minimizing headache-related disability and maximizing health-related quality of life, and avoiding headache escalation and medication misuse. Management of migraine is divided into pharmacologic and nonpharmacologic approaches. Pharmacologic approaches are subdivided into preventive treatment, taken on a daily basis whether or not headache is present, and acute drugs taken to treat individual attacks as they arise. Acute treatments are further divided into nonspecific agents, which work for all types of pain, and migraine-specific treatments. The US Headache Consortium Guidelines recommend stratified care based on the level of disability to help physicians individualize treatment. Using this approach means that simple analgesics are appropriate as first-line acute treatments for less-disabled patients; if simple analgesics are unsuccessful, treatment is escalated for high-end therapies (eg, triptans). For those with high disability levels, migraine-specific acute therapies, such as the triptans, are recommended as the initial treatment, with preventive drugs in selected patients. A variety of behavioral interventions are helpful. The clinician has an armamentarium of ever-expanding variety of medications. With experience, clinicians can match individual patient needs with the specific characteristics of a drug to optimize therapeutic benefit.

The mainstay of migraine treatment is pharmacotherapy. There have been numerous medications used to prevent migraine headaches, including β-blockers, calcium-channel blockers, anticonvulsants, and nonsteroidal anti-inflammatory drugs. Sodium valproate is the only antiepileptic drug approved by the Food and Drug Administration for migraine prevention. Newer antiepileptics, including gabapentin and topiramate, are being evaluated for their role in preventive therapy. The mechanism of action of antiepileptics is not fully understood, but they all share a common role in enhancing gamma-aminobutyric acid-mediated inhibition. This article reviews the role of anticonvulsants in preventive migraine therapy.

Opinion statement

Although alternative therapies are widely used for the treatment of headache disorders, physicians often know little about the available options or about the risks and benefits of the treatments their patients may already be using. Alternative treatments or complementary medicine can provide significant benefit for the headache sufferers, be neutral, distract the headache patient from using more effective therapies, or be harmful. Physicians should take a rational, open-minded approach to the use of alternative and complementary headache treatments.

Antidepressants, particularly tricyclic antidepressants, have been a mainstay in the prophylactic therapy of migraine. The tricyclic antidepressants amitriptyline, nortriptyline, and doxepin have been the major agents for prophylactic treatment of migraine. These cause significant side effects in some patients. The high-affinity selective serotonin reuptake inhibitors and other newer antidepressants have been disappointing and much less effective in the treatment of migraine. In patients who are depressed with severe migraine, a tricyclic antidepressant may treat both conditions; however, the addition of a newer atypical antidepressant may be needed.

The ergot alkaloids were the first specific antimigraine therapy available. However, with the advent of the triptans, their use in the treatment of migraine has declined and their role has become less clear. This review discusses the pharmacology, efficacy, and safety of the ergots. In randomized clinical trials, oral ergotamine was found to be superior to placebo, but inferior to 100 mg of oral sumatriptan. In contrast, rectal ergotamine was found to have higher efficacy (73% headache relief) than rectal sumatriptan (63% headache relief). Intranasal dihydroergotamine was found to be superior to placebo, but less effective than subcutaneous and intranasal sumatriptan. Ergotamine is still widely used in some countries for the treatment of severe migraine attacks. It is generally regarded as a safe and useful drug if prescribed for infrequent use, in the correct dose, and in the absence of contraindications; however, safer and more effective options do exist in the triptans. In patients with status migrainous and patients with frequent headache recurrence, ergotamine is still probably useful.

Background: Migraine headaches have been shown to have substantial personal and societal implications. Health-related quality of life (HRQOL) assessments of migraineurs have been used to monitor and evaluate patient- and population-based outcomes, and to evaluate effectiveness and responsiveness to treatment. In this paper, we test a new, even shorter generic health survey, the SF-8™ Health Survey (SF-8™), an alternate form that uses one question to measure each of the eight SF-36® Health Survey (SF-36®) domains, in a sub-sample of migraine sufferers. Methods: Data from 7557 participants surveyed via the Internet and mail were used to document the burden of migraine on HRQOL and to compare the relative burden of migraine with other chronic conditions using the SF-8. Results: Migraineurs' HRQOL is similar to those with congestive heart failure, hypertension and diabetes, and is better than those with depression. Migraine sufferers experience better physical health and worse mental health (MH) than those with osteoarthritis. Results support prior research indicating that the burden of migraine on functional health and well-being is considerable and comparable to other chronic conditions known to have substantial impact on HRQOL. Conclusions: The SF-8 may provide a more practical and efficient method to describe the burden of migraine in population studies.

Background: While item response theory (IRT) offers many theoretical advantages over classical test theory in the construction and scoring of patient based measures of health few studies compare scales constructed from both methodologies head to head. Objective: Compare the responsiveness to treatment of migraine specific scales scored using summated rating scale methods vs. IRT methods. Methods: The data came from three clinical studies of migraine treatment that used the Migraine Specific Quality of Life Questionnaire (MSQ). Five methods of quantifying responsiveness were used to evaluate and compare changes from pre- to post-treatment in MSQ scales scored using Likert and IRT scaling methods. Results: Changes in all MSQ scale scores from pre- to post-treatment were highly significant in all three studies. A single index scored from the MSQ using IRT methods was determined to be more responsive than any one of the MSQ subscales across the five methods used to quantify responsiveness. Across 13 of the 15 tests (5 responsiveness methods * 3 studies) conducted, the single index scored from the MSQ using IRT methods was the most responsive measure. Conclusions: IRT methods increased the responsiveness of the MSQ to the treatment of migraine. The results agree with the psychometric evidence that suggest that it is feasible to score a single index from the MSQ using IRT methods. This approach warrants further testing with other measures of migraine impact.